NHS Detectives are not grand or rich enough to run a think tank – but we have set up a think paddling pool – please jump right in to our first report.
In June NHS England published a new diabetes “pathway”. This is like a DIY flatpack manual for how commissioners and clinicians should put together what is called:
“an optimal diabetes service, focussing on specific areas of intervention where the return on investment is likely to have the greatest outcomes and cost benefits.”
Although my partner had Type 1 diabetes and died of a hypo, I don’t know anything really about the medical treatment of diabetes. My partner used to go for check ups at the GP surgery every so often, praise the diabetic nurse and grumble about the switch from analogue to digital testing of blood sugar levels. So I have no way of telling if this new “pathway” – or flatpack, which is what it looks like to me – is good bad or indifferent – although the focus on return on investment seems to me to be misplaced. Since when was the NHS a business?
All about payment incentives and mechanisms
A lot of it seems to veer between statements of the bleeding obvious and nitpicking box ticking – eg: the ‘Structured Education: What it means for Commissioners’ slide. And the structured education box ticking seems to be all about payment incentives and mechanisms. More like a private health insurance system than a publicly funded, run and provided NHS.
But that’s what the 5 Year Forward View is all about, isn’t it? Cuts and switching to an American or Spanish-style health insurance system like Medicare or the Alzira Accountable Care Organisation system.
The care planning and annual review happens anyway, as my partner used to regularly go through that. Why do GPs have to be told this? They already do it.
What care planning and annual review means for commissioners comes under the heading of statement of the bleeding obvious. Does NHS England think Clinical Commissioning Groups are stupid?
Well, enough of my layperson’s ramblings. Let’s see what the professionals think.
Seeing patient need in financial pay-off terms
The Advanced Nurse Practioner said,
“This is seeing patient need in complete financial pay-off terms. One of the docs at my place who is on the CCG board said yesterday he believed the area should only have 3 GP practices. He believes patients should pay if they choose to see a GP more than the average 3-4 times a year. It’s all bollocks – the entire focus of health care and need management has turned into a horrible business model.”
“Looking through the pathway properly, how did they come up with its 7 priority focus list? We lack allowance for individual variances & medical decision making nowadays. One-size-fits-all planning may save money, but at the expense of individuals falling through nets. It is appalling reactive decision making machinery.”
It was interesting to hear this, as I’d been thinking that was probably the case, because this is what the “managed care pathways” imported from the USA are all about – restricting the range of treatments/patients to those that the insurance company approves for the Accountable Care Organisation to carry out. It is also about making it possible for Physician Associates to do tick box care, as they will replace the far more qualified and knowledgeable GPs.
But I don’t have the clinical knowledge to judge whether that is what this pathway is about.
Providing standardised diabetes provision on arbitary expected funding per average episode of care
The Advanced Nurse Practitioner said,
“The problem is, although there is a lot of truth and evidence in the preventable aspects of long term conditions like diabetes, change via “Health promotion” is a huge beast and involves many factors.
This “pathway” is reductionist and confines medicine to a formula only loosely based upon best evidence. There is even a paragraph in there that says it’s unevidenced, in that time will tell what focusing on these 7 areas will do for standards.
Standardising care and reducing variability is not a bad thing if the focus is upon reducing inequality in outcomes but to me this reads as though the focus is upon allocating allotted amounts of money to provide standardised diabetes provision on arbitary expected funding per average episode of care.”
We have to acknowledge the preventable aspects of diabetes and other illnesses
I think that kind of nuance is important – we can’t just make knee jerk reactions. We have to acknowledge the preventable aspects of diabetes and other illnesses – but there is also a lot of evidence that growing social and economic inequality is itself a cause of illness, and that it makes it next to impossible for people who are already disadvantaged and so at greater risk of illness, to carry out the preventive measures.
As far as I can see it is a total vicious circle and focusing on individual behaviour change for prevention of illness without tackling the causes of the social and economic inequalities that create health risks in the first place is totally pointless – and worse, amounts to blaming the victims.
The Advanced Nurse Practitioner agreed:
“Absolutely which is why I was gobsmacked that the GP I worked with mentioned charging after standard 4 GP appointments . He said perhaps they could exclude patients with long term conditions . It’s crazy – when does diabetes for example start? When the over 7mmol blood glucose gets read? With pre-diabetes, or somewhere along that creeping scale when the person is experiencing random pre-diabetes symptoms and being a nuisance to their GP?”
The sticking point is money and our local health economies are bust
This is a GP’s response to the new NHS England Diabetes Pathway:
“Diabetes pathways appear eminently sensible with the usual cross cutting themes around integrated working, prevention, care closer to home, expert patients etc. I would love to work in a system like this which could be great for patients and where I am part of a multi-specialty team. The sticking point as ever is money.
Our local health economy like so many is bust. There is no capital to pump prime new models of care and I would question anyone who assumes that new models will be cheaper to run. They can write all the policies they like but without investment they will never be implemented, let alone realise the anticipated benefits.
The pathway is also absolutely conditional on new provider models envisaged by the 5 Year Forward View. Perhaps such policies can be viewed as a drive towards these new models?
5 Year Forward View includes a number of different potential provider models which I guess could be termed Accountable Care Organisations. The current government would like them to be all independent/commercial of course.”
The Advanced Nurse Practitioner added,
“Too right about this. We have to acknowledge the preventable aspects of diabetes and other illnesses but there is also a lot of evidence that growing social and economic inequality is itself a cause of illness and that it makes it impossible for people who are already disadvantaged and so at greater risk of illness, to carry out the preventive measures.
Treating with alternative diets etc for people on low/no income is damn near impossible unless supported educationally. Seeds, no carbs, complex sugars… to a mother with two kids struggling to survive having to start thinking a new diet regime is damn near impossible I would imagine.”
Steven Carne, NHS Detective, said,
“The trouble appears to be that the clinical people are not seeing the WHY, they are only looking at clinical evidence. Campaigners are getting an ear bashing from the docs. And as for the good bits of the pathway, it’s like being in a sewer focusing on one rose over there in the corner.”
The Advanced Nurse Practitioner added:
“I guess in a politically correct fashion that is what the GP was saying too . All well and good holding up these images of what best practice should look like, we’ve seen the evidence, we know the evidence. The problem is there are no staff and resources left to do the sodding work. You’ve spent all the money planning what better health should look like and sold off delivery resources for profit.
The picture the CCG GP guy painted was of fully integrated practice hubs – every available speciality all under three roofs per patch. Faceless medicine where illness is completely defined by a medical definition of any given condition.”
What about tackling the inequitable distribution of power, money and resources – which “are killing people on a large scale”?
A 2016 Study of social inequalities in relation to diabetes and impaired glucose regulation found that social inequalities in hyperglycaemia (high blood sugar) exist. Age standardised prevalence of diagnosed and undiagnosed diabetes and impaired glucose regulation was highest among Asian and black participants. They were also higher among people with lower income, less education, lower occupational class and greater deprivation. Lower or no educational qualifications and low income are significantly associated with impaired glucose regulation or undiagnosed diabetes. (Moody A, et al. BMJ Open 2016;6:e010155. doi:10.1136/bmjopen-2015-010155)
That study’s finding of an association between diabetes and the lowest levels of education is also found in a 2104 report by the OECD observer.
Given this evidence, we have to question the diabetes pathway’s focus on individual behaviour change as the key means of preventing diabetes and improving the health of people with diabetes.
It is a case of what is called “lifestyle drift”.
“Lifestyle drift” is the trend away from tackling the “toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics” which create social injustice that “is killing people on a grand scale” (WHO Commission on social determinants of health), and instead identifying individual lifestyle “choices” as the target for intervention.
This contradicts one of the three key recommendations of the WHO Commission on social determinants of health, which is to:
“tackle the inequitable distribution of power, money and resources.”
Upholding the doctrine that markets rule and profits come before people
Professor Ted Schrecker of Durham and Ottawa Universities, proposes that the ideology of neoliberalism is behind this focus on individual lifestyle “choices” as the target for health promotion schemes. (Ted Schrecker, Beyond “Run, Knit and Relax”, in Healthcare Policy vol 9, Special issue on Population Health and Equity, 2013)
Neoliberalism is the doctrine that markets hold sway over all other social institutions and that the main function of the state is to make sure that this happens, even when this involves intrusive or coercive actions towards its citizens. In other words, money rules and where people stand in the way of profit, they are disposable.
This is directly relevant to the future of population health. Prof Schrecker suggests that the hold that neoliberalism has over health promotion policies and programmes may be attributable to the fact that key public health practitioners and commissioners work in government departments and agencies that are
“subject to strict political direction and control.”
Despite this, a 2010 Journal of Public Health editorial “Injustice is killing people on a large scale—but what is to be done about it?” is clear about the professional duty of “the public health community”. It says:
“…the public health community should … give higher priority to their professional duty to comment publicly on the health consequences of social injustice—a duty highlighted by Bevan in the 1940s. Now is the time for the profession to play a more prominent role in fostering public debate about redistribution and the kind of society people want to be part of.”
We think NHS England’s new diabetes pathway would be better if it acted on this recommendation.
NHS Detectives Think Paddling Pool
This brings together NHS clinicians and other staff, patients, members of the public and NHS protectors, with the aim of inspiring us all to unpick the myriad obvious goals and examples of best practice and ask a few questions about how this is best achieved in the current threadbare system, especially with patients in more difficult circumstances.
We intend this to lead to much debate and cases in point to illustrate what would be involved in the real world to restore person-centred care in a properly resourced, publicly owned, provided and run National Health Service and to introduce effective public health measures in ALL government policy areas.
If you would like to dip a toe in the Think Paddling Pool or even jump right in, please get in touch, via the comments box below. This is moderated before comments go live so if you don’t want your comment to be public, just say.
Some of our next topics to investigate are:
- The use of Quality Outcomes Framework Targets and how they conflict with duty of care to a patient in many ways
- The Care Closer to Home care model’s focus on health promotion by means of individual behaviour change
- Other key bits of the Care Closer to Home model
- What’s happening to Pathology and Radiology services under the Sustainability and Transformation Partnerships
- The 4th Sustainability and Transformation Partnership “gap” – between rhetoric (aka bs) and reality